Eggs and Heart Health: A “hot topic” update for health professionals

Eggs and Heart Health: A “hot topic” update for health professionals

JEN HOUCHINS, PHD, RD

Cardiometabolic Health

Nutritious Dietary Patterns

In 2013, after decades of research, the American Heart Association and the American College of Cardiology published a new guideline on lifestyle management to reduce cardiovascular risk which concluded, “There is insufficient evidence to determine whether lowering dietary cholesterol reduces LDL-cholesterol1.”  This was followed by the removal of the 300 mg per day cholesterol restriction within the 2015 Dietary Guidelines for Americans and a greater focus on overall healthy dietary patterns2.  Today, eggs are recommended as part of heathy eating patterns by both the Dietary Guidelines for Americans and the American Heart Association3,4.  Yet, many people, including health professionals, remain concerned about dietary cholesterol5.

In a new article published in Hot Topics in Primary Care, a special supplement to the Journal of Family Practice, Dr. Maria Luz Fernandez highlights recent research around eggs and cardiovascular health and highlights the evolution of science around the impact of dietary cholesterol on blood cholesterol6.  While the science is clear that elevated LDL-cholesterol increases the risk for cardiovascular disease, the impact of dietary cholesterol and egg intake is not straightforward.  For most people, egg consumption does not impact blood cholesterol levels.  For those whose blood cholesterol responds to dietary cholesterol, generally there is an increase in both LDL-cholesterol and HDL-cholesterol, leaving the ratio between the two unchanged. The ratio of LDL to HDL is recognized as an important indicator of cardiovascular disease risk7.

Further, if there is a change in blood cholesterol secondary to egg consumption, the lipoproteins generated tend to be large, less atherogenic LDL particles that are “preferentially removed by [the] liver rather than by endothelial cells.”  The HDL particles generated secondary to egg consumption have improved functionality and a larger surface area which can transport a higher concentration of carotenoids6.  Overall, these exciting data illustrate that science has moved far beyond looking at the impact of isolated dietary cholesterol on total blood cholesterol, and instead, we are now evaluating the impact of foods (i.e.eggs) on health outcomes.

Most recent publications demonstrate egg consumption is not associated with cardiovascular disease risk8-10, and that is the basis for current guidelines that recommend eggs across the lifespan.  It is important to recognize the benefits of eggs within the diet and their role in optimizing health.  Dr. Fernandez lists several protective effects of eggs6:

  • Generation of HDL-cholesterol with improved function11,12
  • Highly bioavailable lutein and zeaxanthin, carotenoids known to accumulate in the eye and reduce risk of age-related macular degeneration13
  • An excellent source of choline, which is essential for brain health
  • High quality protein for maintenance of health

While the American Heart Association identifies a research gap for people who have abnormal blood lipids4, a growing body of evidence demonstrates eggs can be beneficial even for people at risk of cardiovascular disease11,14,15.  Of course, an overall healthy diet pattern is essential for maintenance of health3,4. For meal inspiration, check out our collection of heart-healthy recipes.

 

Photo by Sara Haas, RDN.

  1. Eckel, R.H., et al., 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 2014. 129(25 Suppl 2): p. S76-99.

  2. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans. 2015; 8:[Available from: http://health.gov/dietaryguidelines/2015/guidelines/].

  3. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2020-2025 Dietary Guidelines for Americans. 2020; Available from: https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf.

  4. Carson, J.A.S., et al., Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation, 2019: p. Cir0000000000000743.

  5. Ipsos, American Egg Board Nutrition Messaging Project. 2021.

  6. Fernandez, M.L., The Role of Eggs in Healthy Diets. Supplement to the Journal of Family Practice, 2022. 71(6): p. S71-S75.

  7. Blesso, C.N. and M.L. Fernandez, Dietary Cholesterol, Serum Lipids, and Heart Disease: Are Eggs Working for or Against You? Nutrients, 2018. 10(4).

  8. Drouin-Chartier, J.P., et al., Egg consumption and risk of cardiovascular disease: three large prospective US cohort studies, systematic review, and updated meta-analysis. Bmj, 2020. 368: p. m513.

  9. Dehghan, M., et al., Association of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries. Am J Clin Nutr, 2020.

  10. Shin, J.Y., et al., Egg consumption in relation to risk of cardiovascular disease and diabetes: a systematic review and meta-analysis. Am J Clin Nutr, 2013. 98(1): p. 146-59.

  11. Sawrey-Kubicek, L., et al., Whole egg consumption compared with yolk-free egg increases the cholesterol efflux capacity of high-density lipoproteins in overweight, postmenopausal women. Am J Clin Nutr, 2019.

  12. Andersen, C.J., et al., Egg consumption modulates HDL lipid composition and increases the cholesterol-accepting capacity of serum in metabolic syndrome. Lipids, 2013. 48(6): p. 557-67.

  13. Johnson, E.J., Role of lutein and zeaxanthin in visual and cognitive function throughout the lifespan. Nutr Rev, 2014. 72(9): p. 605-12.

  14. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Cardiometabolic Risk Factors in Adults at Risk of Type 2 Diabetes. The Journal of Nutrition, 2021. 151(12): p. 3651-3660.

  15. Thomas, M.S., et al., Eggs Improve Plasma Biomarkers in Patients with Metabolic Syndrome Following a Plant-Based Diet-A Randomized Crossover Study.
    Nutrients, 2022.14(10).

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Eggs and Heart Health – A Review of the Latest Research and Reports

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Eggs and Heart Health:

A Review of the Latest Research and Reports

Mickey Rubin, PhD

Cardiometabolic Health

Nutrient-rich eggs are part of heart-healthy diet patterns, according to findings from leading researchers and health authorities

In 2015, the Dietary Guidelines Advisory Committee (DGAC) removed dietary cholesterol from the list of nutrients of public health concern1. Up until that point, there had historically been a limit of 300 milligrams per day for dietary cholesterol, even though eggs were listed as a nutrient-rich food and part of healthy dietary patterns in previous guidelines2.

In making this decision, the 2015 DGA Committee referenced, among other sources, a 2013 systematic review that examined the relationship between egg consumption and cardiovascular disease in almost 350,000 participants across 16 studies3. The review and meta-analysis found no relationship between egg intake and cardiovascular disease, ischemic heart disease, or stroke.

Since 2015, the science evaluating the relationship between dietary cholesterol, eggs, and cardiovascular health has continued to grow4,5, with several new research studies and authoritative reports building on our existing knowledge.

 

LATEST RESEARCH FINDINGS FROM OBSERVATIONAL COHORTS

There are often competing headlines in nutrition science, with one study showing one thing, and another study showing the opposite. This is often true with a nutrient like cholesterol – or a food like eggs – in which our knowledge has evolved considerably over the years. Rather than getting caught with nutrition science whiplash, it is important to not focus too much on any one study, but rather view the research in totality.

For example, one observational study of U.S. cohorts published early in 2019 found a small but statistically significant increase in cardiovascular risk with egg consumption6. However, another observational study published just a few weeks later and analyzing data from over 400,000 men and women in Europe for over an average of 12 years, found a small but statistically significant decrease in risk for ischemic heart disease with egg intake7. While these two examples appear similar in design and provide conflicting results, additional studies published later in the year had design aspects that provided unique insights.

 

PURE Cohort Results Reinforce Earlier Findings and Identify New Insights
A study published in the American Journal of Clinical Nutrition assessed the association of egg consumption with blood lipids, cardiovascular disease, and mortality in three large international cohorts8.  In one cohort, the Prospective Urban Rural Epidemiology (PURE) study, egg consumption was assessed in 146,011 individuals from 21 countries. The researchers also studied 31,544 patients with vascular disease in 2 multinational studies: ONTARGET and TRANSCEND, both of which were originally designed to test treatments for hypertension.

The findings from the PURE cohort found no link between egg consumption and cardiovascular disease outcomes. In fact, in the PURE cohort, researchers found that higher egg intake was associated with a lower riskof myocardial infarction, a finding that is consistent with other recent studies of cohorts outside the U.S.7. In the ONTARGET and TRANSCEND cohorts of individuals with vascular disease, the researchers also reported no link between egg consumption and cardiovascular events.

Thus, these findings from the PURE investigators reinforce previous research regarding egg consumption in otherwise healthy individuals, but took a big step forward in our understanding of this relationship in individuals with vascular disease.


Harvard School of Public Health Findings Reveal Decades of Strong Evidence
Yet another study was published in 2020 that was a follow-up to a landmark investigation first published in 1999. The original study, led by Hu and colleagues from the Harvard School of Public Health, reported no relationship between egg intake and coronary heart disease or stroke in women from the Nurses’ Health Study (NHS) cohort and men from the Health Professionals Follow-Up Study (HPFS) cohort9.  At that time the researchers concluded that an egg a day did not impact heart disease or stroke risk.

The current study, an updated analysis of the study published in 1999, includes up to 32 years of follow-up and extends the analysis to the younger cohort of Nurses’ Health Study II10. Thus, this latest analysis included 83,349 women from NHS; 90,214 women from NHS II; and 42,055 men from HPFS. Additionally, to compare these new findings to the extensive literature base on the topic of egg intake and cardiovascular risk, the researchers performed a systematic review and meta-analysis of 27 other published studies from the U.S., Europe, and Asia.

Results from the updated analysis from NHS, NHS II, HPFS, as well as the updated meta-analysis of global cohorts are consistent:

  • Egg consumption of one egg per day on average is not associated with cardiovascular disease risk overall
    • Results were similar for coronary heart disease and stroke
  • Egg consumption seems to be associated with a slightly lower cardiovascular disease risk among Asian cohorts

An important strength of this study is the use of repeated dietary assessments over the course of several decades in contrast to some observational cohorts which utilize only a single dietary measure at enrollment. According to the authors, it is desirable to have repeated dietary assessments over time to account for variation of dietary intake and other factors that contribute to atherosclerosis.

The studies from the PURE cohort and Harvard School of Public Health make significant contributions to the scientific literature on egg intake and cardiovascular health. These results are also consistent with the 2015 Dietary Guidelines recommendation that cholesterol is not a nutrient of public health concern.

 

NEW RECOMMENDATIONS FROM LEADING HEALTH AUTHORITIES

In the past year, we have also had multiple recommendations from leading health authorities that have assessed the totality of evidence for dietary cholesterol and cardiovascular disease, as well as the role of eggs in heart-healthy diet patterns across the lifespan. A common theme from these authoritative recommendations is that eggs can be a part of heart-healthy diet patterns, and in some cases nutrient dense eggs should be emphasized in diet patterns due to their unique nutrient package.

American Heart Association: Eggs Fit in Heart-Healthy Diet Patterns
In late 2019, the American Heart Association (AHA) Nutrition Committee published a science advisory on Dietary Cholesterol and Cardiovascular Risk11. According to the authors, “the elimination of specific dietary cholesterol target recommendations in recent guidelines has raised questions about its role with respect to cardiovascular disease.” This review examined evidence from observational cohorts and randomized controlled trials and concluded that “a recommendation that gives a specific dietary cholesterol target within the context of food-based advice is challenging for clinicians and consumers to implement; hence, guidance focused on dietary patterns is more likely to improve diet quality and to promote cardiovascular health.” The science advisory recommends heart-healthy eating patterns such as the Mediterranean-style and DASH (Dietary Approaches to Stop Hypertension)–style diets. Specifically, regarding eggs, the advisory concluded:·

  • Healthy individuals can include up to a whole egg daily in heart-healthy dietary patterns.
  • For older healthy individuals, given the nutritional benefits and convenience of eggs, consumption of up to 2 eggs per day is acceptable within the context of a heart-healthy dietary pattern.
  • Vegetarians who do not consume meat-based cholesterol-containing foods may include more eggs in their diets within the context of moderation.

Australian Heart Foundation: No Evidence to Limit Egg Consumption
It wasn’t only the American Heart Association that clarified the role of eggs in a heart-healthy diet, but the Australian Heart Foundation (AHF) made similar recommendations with a new position statement on eggs and cardiovascular health12The AHF summary of evidence concluded there is no evidence to suggest any limit on egg consumption for normal, healthy individuals. The review does suggest a limit to fewer than 7 eggs per week for those with type 2 diabetes or cardiovascular disease that require LDL cholesterol- lowering interventions.

Both the AHA and AHF guidelines were clearly a step forward, building on the knowledge that dietary cholesterol is not a nutrient of concern in healthy individuals.

A growing body of evidence indicates that nutrient-rich eggs can also be enjoyed as part of healthy dietary patterns for those at risk for cardiovascular disease.

There appears to be agreement that eggs can be included as part of healthy dietary patterns for healthy people, however, the AHA continues to place caution on eating food higher in cholesterol for those with abnormal blood cholesterol, “…particularly those with diabetes mellitus or at risk for heart failure…11.” While this is an area of ongoing research, a growing body of evidence supports eggs as an important addition to the diet even for those at risk for cardiovascular disease.

Recent studies have explored how eating eggs can impact blood cholesterol and health outcomes in people who are at risk for heart disease:

  • Eating two eggs daily improved the function of HDL (good) cholesterol and did not impact total cholesterol, HDL cholesterol, or LDL cholesterol in postmenopausal women who were overweight13.
  • Adding three eggs per day to the diet of people who have metabolic syndrome did not increase LDL (bad) cholesterol.  “…whole eggs could be considered a healthful food choice for people with metabolic syndrome14.”
  • There was no link between egg consumption and cardiovascular events in 31,544 patients with vascular disease in two multinational studies (ONTARGET and TRANSCEND)8.
  • Consumption of cholesterol from eggs is linked to lower mortality among people with high blood pressure, while consumption of cholesterol from other foods is linked to higher mortality.  However, total cholesterol is not related to mortality among a sample of people with high blood pressure who live in China15.
  • Eating two eggs daily, as part of a plant-based diet, did not adversely affect markers of heart health in adults at risk for type 2 diabetes.  In fact, eating eggs improved self-reported intake of selenium and choline16.
  • Adding two eggs + spinach to breakfast, as part of a plant-based healthy diet, improved body weight and HDL-cholesterol in people with metabolic syndrome.  There were no differences observed in plasma LDL-cholesterol, triglycerides, glucose, insulin, or blood pressure between the intervention and control group17.

Overall, these findings support that including eggs, as part of healthy dietary patterns, may be beneficial even for people at risk of CVD11.  Healthy dietary patterns include a variety of vegetables, fruits (especially whole fruit), whole grains, dairy foods, protein foods (including lean meats, poultry, eggs, seafood, beans, peas, lentils, nuts, seeds, and soy products), and oils (including oils in foods)18.

 

SUMMARY

The science on dietary cholesterol and eggs continues to grow and demonstrates that eggs are an important part of healthy dietary patterns across the lifespan. Overall, these data support the value of eggs as a nutrient dense food within healthy dietary patterns. Eggs are a good or excellent source of eight essential nutrients including choline and high-quality protein, plus 252 mcg of the carotenoids lutein and zeaxanthin. The 70-calorie egg is an exceptionally nutrient-rich choice that can help improve dietary intake and optimize health.

See our recipes that fit into a heart-healthy diet or heart health toolkit for more information.

 
  1. Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture,. 2015; Available from: https://health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf.

  2. U.S. Department of health and Human Services and U.S. Department of Agriculture. 2010 Dietary Guidelines for Americans. 2010; Available from: https://www.dietaryguidelines.gov/about-dietary-guidelines/previous-editions/2010-dietary-guidelines.

  3. Shin, J.Y., et al., Egg consumption in relation to risk of cardiovascular disease and diabetes: a systematic review and meta-analysis. Am J Clin Nutr, 2013. 98(1): p. 146-59.

  4. Fernandez, M.L. and A.G. Murillo, Is There a Correlation between Dietary and Blood Cholesterol? Evidence from Epidemiological Data and Clinical Interventions. Nutrients, 2022. 14(10).

  5. Fernandez, M.L., The Role of Eggs in Healthy Diets. Supplement to the Journal of Family Practice, 2022. 71(6): p. S71-S75.

  6. Zhong, V.W., et al., Associations of Dietary Cholesterol or Egg Consumption With Incident Cardiovascular Disease and Mortality. Jama, 2019. 321(11): p. 1081-1095.

  7. Key, T.J., et al., Consumption of Meat, Fish, Dairy Products, Eggs and Risk of Ischemic Heart Disease: A Prospective Study of 7198 Incident Cases Among 409,885 Participants in the Pan-European EPIC Cohort. Circulation, 2019.
  8. Dehghan, M., et al., Association of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries. Am J Clin Nutr, 2020.

  9. Hu, F.B., et al., A prospective study of egg consumption and risk of cardiovascular disease in men and women. Jama, 1999. 281(15): p. 1387-94.

  10. Drouin-Chartier, J.P., et al., Egg consumption and risk of cardiovascular disease: three large prospective US cohort studies, systematic review, and updated meta-analysis. Bmj, 2020. 368: p. m513.

  11. Carson, J.A.S., et al., Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation, 2019: p. Cir0000000000000743.

  12. National Heart Foundation of Australia. Summary of Evidence: Eggs & Cardiovascular Health. 2019; Available from: https://www.heartfoundation.org.au/getmedia/c1f95635-f0cb-4d9f-8221-f08463e61975/Nutrition_Evidence_papers_-_Summary_EGGS_FINAL.pdf.

  13. Sawrey-Kubicek, L., et al., Whole egg consumption compared with yolk-free egg increases the cholesterol efflux capacity of high-density lipoproteins in overweight, postmenopausal women. Am J Clin Nutr, 2019.

  14. DiBella, M., et al., Choline Intake as Supplement or as a Component of Eggs Increases Plasma Choline and Reduces Interleukin-6 without Modifying Plasma Cholesterol in Participants with Metabolic Syndrome.Nutrients, 2020. 12(10).

  15. Wu, F., et al., Egg and Dietary Cholesterol Consumption and Mortality Among Hypertensive Patients: Results From a Population-Based Nationwide Study. Frontiers in Nutrition, 2021. 8(830).

  16. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Cardiometabolic Risk Factors in Adults at Risk of Type 2 Diabetes. J Nutr, 2021.

  17. Thomas, M.S., et al., Eggs Improve Plasma Biomarkers in Patients with Metabolic Syndrome Following a Plant-Based Diet-A Randomized Crossover Study. Nutrients, 2022. 14(10).

  18. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2020-2025 Dietary Guidelines for Americans. 2020; Available from: https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf.

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Egg Design Contest

2023 Egg Design Submission Call

2023 Egg Design Submission Call

Presented by America’s Egg Farmers

For over 40 years, the First Lady of the United States is presented with a beautifully decorated Commemorative Easter Egg by America’s egg farmers to celebrate Easter. To mark the 2022 Easter season, all 40 eggs presented to past First Ladies were displayed in a special exhibit.

During the 2023 Easter season, a new exhibit will feature decorated eggs from each U.S. state/territory designed by kids across the country. We are calling on parents with kids aged 5-18 to design an egg under the theme of “United States of Possibility” that represents their home U.S. state or territory.

The American Egg Board selection committee will review all submissions and select one egg design per state/territory. Selected winners will be notified by March 10, 2023, and selected egg designs will be created by egg artists across the country for the special exhibit.

 

United States of Possibility Theme - How to Get Your Child Started

Each U.S. state and territory is special. From the mountain ranges of Washington to farmlands of Iowa to beaches in Florida, our different locations combined make up a diverse and united country and give us a special sense of local and national pride. So how can our differences contribute to the future of the United States?

This is the United States of Possibility. What role will your individual state or territory play in the next 5, 10 or 15 years? What are some special aspects that you think will contribute to our country’s unity? We’re looking for egg designs that show how your state/territory might make a difference in the future of our country. Consider your home’s unique natural resources, scientific and technological inventions or cultural developments in the arts, sports or film. Then put it into an egg design…

Here are some questions to ask your child when thinking about their egg design:

  • What is the thing I love most about my state or territory?
  • What makes my state/territory unique?
  • What makes my state’s/territory’s citizens different?
  • And how can any of these things contribute to the unity of our country in the future?

Submit Your Child’s Egg Design Entry

Download the submission form below and use the template provided to have your child create their own egg design and corresponding design inspiration statement explaining your child’s vision behind the idea. Encourage your child to embrace their personal artistic style, using any medium of choice. Art should be your child’s original creation.

Fully complete the uploaded submission form, including your contact information and your child/artist’s name before uploading. All submissions are due to the portal below by 11:59:59 PM EST on Saturday, December 31, 2022. Parents of selected egg design submissions will be notified by March 10, 2023.

2023 Egg Design Submission Call

2023 White House Egg Design Submission Contest Rules

For full rules and terms and conditions for entering this contest opportunity with American Egg Board, please visit www.incredibleegg.org/unitedstatesofpossibility/rules.

Growing evidence supports eggs as a beneficial addition to healthy diets, even for people who are at higher risk for cardiovascular disease

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Growing evidence supports eggs as a beneficial addition to healthy diets, even for people who are at higher risk for cardiovascular disease

Jen Houchins, PhD, RD

Cardiometabolic Health

Nutritious Dietary Patterns

The American Heart Association (AHA) Science Advisory: Dietary Cholesterol and Cardiovascular Risk indicates that “healthy individuals can include up to a whole egg or equivalent daily” as part of a heart-healthy dietary pattern.  “For older normocholesterolemic patients, given the nutritional benefits and convenience of eggs, consumption of up to 2 eggs per day is acceptable within the context of a heart-healthy dietary pattern1.”  The AHA expresses caution, however, around the consumption of dietary cholesterol for patients with dyslipidemia, suggesting a gap in research for a subgroup of the population at risk for cardiovascular disease.  Of importance, a growing body of evidence indicates that eating eggs as part of a healthy diet does not negatively impact blood cholesterol levels and may benefit health, even in people at risk for cardiovascular disease2-5.

A recent randomized controlled crossover intervention recruited 30 men and women aged 35-70 with metabolic syndrome (MetS) to follow a plant-based healthy diet (excluding meat, poultry, fish, and seafood) for 13 weeks.  Participants were randomized to eat spinach with two eggs for breakfast or spinach with egg substitute and then crossed over to the opposite intervention.  The data showed lower body weight and higher HDL cholesterol after the egg intervention compared to the substitute.  No differences were observed in plasma LDL cholesterol, triglycerides, glucose, insulin, or blood pressure.  Blood levels of choline were higher after the egg intervention compared to the substitute; lutein increased during both interventions, and zeaxanthin increased only after the egg intervention.  The authors conclude, “This study demonstrates that consuming whole eggs in combination with a plant-based diet offers a healthier dietary pattern when compared to egg substitutes by favorably affecting plasma lipids and antioxidant carotenoids, as well as choline, thereby reducing disease risk3.”

Importantly, this is also consistent with other studies that have similarly found a beneficial impact of including eggs in the diet:

  • Thirty-five adults at risk for type 2 diabetes mellitus included two eggs daily in the context of a plant-based (vegan) diet for six weeks. Eating eggs improved diet quality without adversely impacting cardiometabolic risk factors when compared to egg exclusion4,6.
  • Twenty overweight, postmenopausal women added two whole eggs to the diet for four weeks. This study found improvement in HDL function (cholesterol efflux capacity) with no other changes in lipid biomarkers when compared to eating egg whites only5.

While more research is always needed, these recent intervention studies support the value of eggs as part of healthy dietary patterns for everyone, regardless of cardiovascular disease risk status.  For heart-healthy recipe ideas, please see our collection of recipes here.

  1. Carson, J.A.S., et al., Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation, 2019: p. Cir0000000000000743.
  2. DiBella, M., et al., Choline Intake as Supplement or as a Component of Eggs Increases Plasma Choline and Reduces Interleukin-6 without Modifying Plasma Cholesterol in Participants with Metabolic Syndrome. Nutrients, 2020. 12(10).
  3. Thomas, M.S., et al., Eggs Improve Plasma Biomarkers in Patients with Metabolic Syndrome Following a Plant-Based Diet-A Randomized Crossover Study. Nutrients, 2022. 14(10).
  4. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Diet Quality in Adults at Risk for Type 2 Diabetes: A Randomized Single Blind Cross-over Controlled Trial. Journal of the American Nutrition Association, 2022: p. 1-10.
  5. Sawrey-Kubicek, L., et al., Whole egg consumption compared with yolk-free egg increases the cholesterol efflux capacity of high-density lipoproteins in overweight, postmenopausal women. Am J Clin Nutr, 2019.
  6. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Cardiometabolic Risk Factors in Adults at Risk of Type 2 Diabetes. The Journal of Nutrition, 2021. 151(12): p. 3651-3660.

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Nutritious Comfort Food

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Nutritious Comfort Food

Jessica Ivey, RDN

Nutritious Dietary Patterns

The Egg Nutrition Center partnered with Jessica Ivey, RDN, LDN to write this blog post.


Crave-worthy comfort foods and hearty, rich dishes may not be especially nutrient-rich, but with a few upgrades, you can enjoy your favorite fare with more nutrition in each bite.

Include a source of high-quality protein.

The Dietary Guidelines for Americans (DGA) recommend including a variety of protein options, such as seafood, skinless poultry, lean pork, such as pork tenderloin or center-cut pork chops, and lean beef, like sirloin steaks or roast and 90% lean ground beef. Eggs are also a high-quality protein source, providing 6 grams of protein per large egg and all nine essential amino acids, for only 70 calories. Vegetarian sources of protein, such as soy products, legumes, nuts, and seeds can also be included regularly. Diets rich in high-quality protein have been shown to help people feel full and satisfied after eating, control their appetite and manage their body weight. Additionally, eating meals with 20-30 grams of protein helps promote muscle protein synthesis, and supports the maintenance of healthy muscle with aging. Eggs can be enjoyed throughout the day! While eggs are traditionally viewed as a go-to breakfast food, they also make great snacks or a delicious protein option in balanced lunches and dinners. One of my favorite easy dinner recipes on a busy night is a family favorite pizza, and I love this Hawaiian Scrambled Egg Pizza for added protein.

Incorporate a hefty helping of vegetables.

Eggs make it easy to follow a plant-based diet because they pair well with vegetables, which are foods Americans often don’t eat enough of.1 But don’t forget the yolks folks. Nearly half of an egg’s protein and most of its vitamins and minerals – including those essential for supporting our brains and bodies — are found in the yolk. Eggs and vegetables are a perfect pairing because vegetables are a source of many of the nutrients lacking in the typical American diet, including vitamin A, C, folate, fiber, magnesium, and potassium.1 Incorporating more vegetables into comforting dishes you already enjoy is a great way to boost the nutritional value of the meal and adding eggs can help you better absorb the nutrients found in vegetables, such as vitamin E and carotenoids.2,3 One of my favorite comforting classics is spaghetti, and I love the idea of trading half the pasta for zucchini noodles in this Pasta Carbonara with Mixed Noodles.

Choose whole grains.

Whole grains are foods made from the entire grain kernel, which is made up of the bran, endosperm, and germ, and they thus retain more nutrients than refined grains. Whole grains are an important source of dietary fiber, iron, and folate, and the Dietary Guidelines recommend that we make at least half our grains whole to reduce the risk of coronary heart disease.1 Eggs are also recommended for healthy adults as part of a heart-healthy diet according to the American Heart Association. Examples of whole grains include whole-wheat bread, brown rice, whole-wheat pasta, and quinoa. These Stuffed Peppers with Quinoa and Eggs fit into a heart-healthy diet and would be a nutrient-packed alternative to traditional stuffed peppers with white rice and beef.

Jessica Ivey, RDN, LDN, is a dietitian and chef with a passion for teaching people to eat healthy for a happy and delicious life. Jessica offers approachable healthy living tips, from fast recipes to meal prep guides and ways to enjoy exercise on her website, JessicaIveyRDN.com. Follow her on Facebook and Instagram.

  1. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015-2020 Dietary Guidelines for Americans. 2015; 8:[Available from: http://health.gov/dietaryguidelines/2015/guidelines/].
  2. Kim, J.E., M.G. Ferruzzi, and W.W. Campbell, Egg Consumption Increases Vitamin E Absorption from Co-Consumed Raw Mixed Vegetables in Healthy Young Men. J Nutr, 2016. 146(11): p. 2199-2205.
  3. Kim, J.E., et al., Effects of egg consumption on carotenoid absorption from co-consumed, raw vegetables. Am J Clin Nutr, 2015. 102(1): p. 75-83.

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When is an egg not just an egg? The importance of global food systems

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When is an egg not just an egg? The importance of global food systems

Mickey Rubin, PhD

Global Food Systems

Nutritious Dietary Patterns

As our world becomes increasingly interconnected, we each have a role to play in ensuring that food is accessible for all – while also being good for us and the planet. As dietitians and healthcare professionals, we are aware of how the foods we choose to eat not only impact our health, but also the larger food system. That’s why we’re excited to share more about important conversations taking place on the global level. In September 2021, the UN Secretary-General convened the first-ever United Nations Food Systems Summit (UNFSS) to bring widespread attention to topics such as sustainability, food systems, and global health.

Dietitians play an integral role in promoting sustainability because they are highly skilled in translating complex science to patients and harness interpersonal skills to change patient behavior. Plus, dietitians understand the importance of both healthy diets and promoting a sustainable food system.

As such, dietitians recommend certain foods to patients to promote good nutrition and other health goals. Eggs and beans have long been regarded as highly nutritious foods – both are a source of protein and key nutrients. In addition to being nutritious foods to include in the diet, the UNFSS formally recognized eggs and beans as “star ingredients” as part of World Food Day 2021. The UNFSS video, When Is An Egg Not Just An Egg?, highlights the key role that eggs play in diets around the world; they’re accessible, nutritious, and full of potential for fueling our bodies. The video The Magic of Beans highlighted beans as a versatile, affordable, and nutritious food for people around the world. These videos help promote the importance of food systems conversations and show that eggs and beans are fuel for our future.

So, what do you mean by food systems?

Food systems refer to the collective activities involved in the production, processing, transportation, consumption, and disposal of food. They encompass the physical health of people, as well as healthy environments, economies, and cultures. Registered dietitians play a critical role in food systems, helping patients build nutritious dietary patterns while considering the affordability, accessibility, and cultural context of food choices.

And, what happened at the UNFSS and why is it important?

UNFSS was convened as part of the Decade of Action on Nutrition to achieve the Sustainable Development Goals(SDGs). Promoted as a “people’s summit, UNFSS assembled key actors across global food systems, with over 51,000 attendees from 193 countries. It included five Action Tracks to draw on the expertise of different stakeholders, two of which included nutrition and sustainable consumption:

  • Action Track 1 concentrated on ensuring access to safe and nutritious food for all, with the goal of ending hunger and malnutrition in all its forms. This Action Track launched conversations on food safety, access to school meals, workforce nutrition, and more.
  • Action Track 2 covered sustainable consumption patterns, looking to build consumer demand for sustainably produced food, strengthen local value chains, improve nutrition, and promote the reuse and recycling of food resources. This Action Track examined the role of food environments, demand creation, and food loss and waste.

UNFSS was the first major global gathering around food systems. It resulted in coalition-building among stakeholders, national commitments from governments, and cross-cutting priorities for global nutrition organizations. Undoubtedly, the high-level conversations launched at UNFSS will drive nutrition commitments and food policy for decades to come.

Interested in learning how you can take action on food systems? Follow UNFSS on Twitter or Instagram for announcements of new coalitions, podcasts on global food systems, as well as opportunities for health professionals and other stakeholders to get involved.

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Choline during pregnancy: new study shows lasting cognitive benefit for children

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Choline during pregnancy: new study shows lasting cognitive benefit for children

Jen Houchins, Phd

Nutrients in Eggs

Nutritious Dietary Patterns

Getting enough choline is important throughout the lifespan, but it is especially critical during pregnancy and lactation to support the baby’s brain development.1,2  Previous research demonstrated that choline supplementation during the third trimester of pregnancy can improve an infant’s cognitive function,3 and a recently published follow-up study with this same group of children found a lasting impact into school-age years.4  While larger studies will need to confirm these human data, the current evidence demonstrates higher maternal choline intake during pregnancy can have a lasting beneficial impact on children’s brain health and development.

Previously, a randomized, double-blind, controlled feeding study found that higher maternal choline supplementation during the third trimester of pregnancy (930 vs. 480 mg/day) improved infant information processing speed (a measure of cognitive function).  Importantly, a benefit was also seen at the lower level of intake for infants born to mothers who were enrolled in the study for a greater duration of pregnancy.  The authors concluded, “even modest increases in maternal choline intake during pregnancy may produce cognitive benefits for offspring.”3

As a follow-up, the same children from this initial study were assessed at seven years old.  Children born to women who were in the 930 mg supplementation group demonstrated superior performance in sustained attention (a measure of cognitive function), compared to children in the 480 mg supplementation group.4  The long-term benefits of choline supplementation during pregnancy are hypothesized to be at least partly due to lasting changes during brain development, which would be consistent with animal studies.  While these results strongly support a beneficial impact of higher choline intake during pregnancy, the authors recommend larger studies in more diverse populations to confirm the observations.  Further, more research is needed to determine the optimal level of choline intake during pregnancy.

Most Americans, including pregnant women (average choline intake of 350 mg/day), do not meet the Adequate Intake for choline.2,4,5  With these new human data supporting the critical role of higher choline intake during early life, consuming choline-rich foods (along with a supplement if indicated), are encouraged as part of healthy dietary patterns.5,6  Importantly, one large egg provides several nutrients essential for brain growth, including 150 mg choline.7,8  A large egg also provides 252 mcg of lutein + zeaxanthin, carotenoids with emerging evidence linking to brain development and health.9  Other nutrient-rich foods that can help provide choline to the diet include meat, soybeans, poultry, fish, dairy products, potatoes with skin, wheat germ, quinoa, cruciferous vegetables, nuts, and seeds.10

“Meeting nutrient needs through foods and beverages is preferred, but women who are concerned about meeting recommendations should speak with their healthcare provider to determine whether choline supplementation is appropriate.”11  For more information about choline, see the National Institutes of Health Choline Fact Sheet for Health Professionals and Choline Throughout the Lifespan article. For recipe inspiration, check out IncredibleEgg.org.

  1. Wallace, T.C. and V.L. Fulgoni, 3rd, Assessment of Total Choline Intakes in the United States. J Am Coll Nutr, 2016. 35(2): p. 108-12.
  2. Wallace, T.C. and V.L. Fulgoni, Usual Choline Intakes Are Associated with Egg and Protein Food Consumption in the United States. Nutrients, 2017. 9(8).
  3. Caudill, M.A., et al., Maternal choline supplementation during the third trimester of pregnancy improves infant information processing speed: a randomized, double-blind, controlled feeding study. Faseb j, 2018. 32(4): p. 2172-2180.
  4. Bahnfleth, C.L., et al., Prenatal choline supplementation improves child sustained attention: A 7-year follow-up of a randomized controlled feeding trial. Faseb j, 2022. 36(1): p. e22054.
  5. Wallace, T.C., et al., Choline: The Neurocognitive Essential Nutrient of Interest to Obstetricians and Gynecologists. J Diet Suppl, 2019: p. 1-20.
  6. Caudill, M.A., et al., Building better babies: should choline supplementation be recommended for pregnant and lactating mothers? Literature overview and expert panel consensus. Eur Gyn Obstet, 2020. 2: p. 149-61.
  7. U.S. Department of Agriculture. FoodData Central SR Legacy — Egg, whole, raw, fresh. 2019 April 1, 2019; Available from: https://fdc.nal.usda.gov/fdc-app.html#/food-details/171287/nutrients.
  8. Schwarzenberg, S.J. and M.K. Georgieff, Advocacy for Improving Nutrition in the First 1000 Days to Support Childhood Development and Adult Health. Pediatrics, 2018. 141(2).
  9. Wallace, T.C., A Comprehensive Review of Eggs, Choline, and Lutein on Cognition Across the Life-span. J Am Coll Nutr, 2018. 37(4): p. 269-285.
  10. National Institutes of Health. Choline: Fact Sheet for Health Professionals. 2021; Available from: https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/.
  11. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2020-2025 Dietary Guidelines for Americans. 2020; Available from: https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf.

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New study for aging adults: egg intake associated with slower rate of memory decline

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New study for aging adults: egg intake associated with slower rate of memory decline

Jen Houchins, PhD

Cognition

Nutritious Dietary Patterns

By 2030, one in five Americans will be aged 65 years and older, and for some of these aging adults, cognitive and memory issues can impact their day-to-day functioning and quality of life.1  There is growing interest in the possible role of healthy eating to protect against later cognitive impairment, and new data continue to support eggs as an important food to help support healthy aging. 

A recent study supported by the American Egg Board found that consuming even limited amounts of eggs (about 1 egg per week) was linked to slower memory decline later in life compared to consuming no eggs.2  While more investigations are needed to evaluate if higher egg consumption may have a stronger impact, these data support an important role for eggs as part of the diet for older adults.

This new study evaluated data from 470 participants 50 years and older in the Adventist Health Study-2 to examine if egg intake levels predict the rate of memory decline.  Egg consumption was divided into low (about half an egg), intermediate (half to 1 ½ eggs), and high (about two or more eggs).  The low egg intake group had the largest rate of memory decline over time, and while there was no difference detected at age 50 or 60, lower memory performance was observed at age 70 and 80.  Over time, the intermediate egg group had significantly lower rate of decline in memory performance compared to the low egg intake group.  In other words, even a very small amount of egg included in the diet (as little as ½ to 1 egg per week) was associated with a beneficial impact on memory.

This study is unique not only because it evaluated memory over time (instead of just one point in time), but also because it evaluated the impact of eggs alone, with adjustment for other foods in the diet.  More studies are needed to evaluate if higher egg consumption can have a stronger impact on maintaining cognitive function over time in aging adults.  Further, while the large number of participants in this cohort helps to establish relationships, intervention trials are needed to establish causality.

The American Heart Association recommends up to 2 eggs per day for healthy (normocholesterolemic) older adults within a healthy dietary pattern.3  Eggs have a unique nutrient package that may be especially beneficial to aging adults, who generally have lower calorie requirements but increased nutrient needs.4  Eggs are a good source of high-quality protein and an excellent source of vitamin B12, as well as nutrients that are underconsumed by the entire population including choline (25% DV in a large egg) and vitamin D (6% DV in a large egg).  Finally, the 252 mcg lutein + zeaxanthin give the yolk its yellow color.  These carotenoids accumulate in the macula of the eye and have been associated with reduced risk of age-related macular degeneration.5 

For ideas of how to incorporate eggs into a healthy diet, please see our recipe collection, including the heart-healthy recipes!

  1. Centers for Diesease Control and Prevention. Chronic Diseases and Cognitive Decline — A Public Health Issue. 2020; Available from: https://www.cdc.gov/aging/publications/chronic-diseases-brief.html.

  2. Lee, G.J., et al., Egg intake moderates the rate of memory decline in healthy older adults. Journal of Nutritional Science, 2021. 10: p. e79.

  3. Carson, J.A.S., et al., Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation, 2019: p. Cir0000000000000743

  4. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2020-2025 Dietary Guidelines for Americans. 2020; Available from: https://www.dietaryguidelines.gov/sites/default/files/2020-12/Dietary_Guidelines_for_Americans_2020-2025.pdf.

  5. Mares, J., Lutein and Zeaxanthin Isomers in Eye Health and Disease. Annu Rev Nutr, 2016. 36: p. 571-602.

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New Study Shows Value of Eggs as Part of Plant-Based Diets for People at Risk for Diabetes

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New study shows value of eggs as part of plant-based diets for people at risk for diabetes

Mickey Rubin, Phd & Jen houchins, PHD

Nutritious Dietary Patterns

A new study demonstrates adding eggs to plant-based diets in people who are at risk of type 2 diabetes mellitus (T2DM) can improve nutrient intake without impacting cardiovascular risk.1  In this study, plant-based diets were based on the USDA healthy vegetarian meal plan, with modifications to exclude eggs and dairy products.    

This randomized, controlled trial included two dietary interventions: 1) six weeks of an exclusively plant-based diet with no animal-sourced foods or, 2) six weeks of an exclusively plant-based diet + 2 eggs per day. Participants were individuals at risk for T2DM.

Results showed that including two eggs per day in the otherwise exclusively plant-based diet had no impact on measures of cardiometabolic health, including endothelial function, lipid profile, blood pressure, insulin sensitivity, or body weight, despite an expected increase in dietary cholesterol intake. This is consistent with dietary recommendations that indicate eggs can be part of overall healthy diet patterns.2 Importantly, including eggs in a plant-based diet did significantly improve selenium and choline intakes, while there was a decrease in calcium and vitamin K intake.

Choline is important for the brain, nervous system and membranes that surround the body’s cells.3,4  Importantly, the plant-based diet + eggs significantly improved dietary choline intake, but at 410 mg/day, this still does not reach the Adequate Intake (AI) for women. These data show that careful planning is required to meet choline intake, and it might be especially difficult to meet the AI without eating eggs or taking a dietary supplement.5 Additionally, selenium has wide ranging functions and can support overall cardiovascular and immune health.6

This study is particularly strong in demonstrating the value of eggs as part of plant-based diets because other animal-sourced foods have been removed from the intervention. In this way, these new data were able to isolate the impact of eggs and showed no impact on indicators of cardiometabolic health.  However, animal-sourced foods can be important for meeting nutrient needs, as illustrated by inadequate calcium during this study potentially due to exclusion of dairy foods. 

Overall, this new study demonstrates that consuming two eggs daily as part of plant-based diets does not impact cardiometabolic risk factors in adults at risk for T2DM. The authors state, “Eggs could be used as an adjuvant to enhance plant-based diets that are typically recommended for those at risk of T2DM.1”  While larger trials are needed, these new data build on existing literature demonstrating the value of eggs as part of healthy diet patterns for people who have diabetes or are at risk for diabetes.7-11

  1. Njike, V.Y., et al., Egg Consumption in the Context of Plant-Based Diets and Cardiometabolic Risk Factors in Adults at Risk of Type 2 Diabetes. J Nutr, 2021.
  2. Carson, J.A.S., et al., Dietary Cholesterol and Cardiovascular Risk: A Science Advisory From the American Heart Association. Circulation, 2019: p. Cir0000000000000743.
  3. National Institutes of Health. Choline: Fact Sheet for Health Professionals. 2021; Available from: https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/.
  4. National Institutes of Health. Selenium: Fact Sheet for Health Professionals. 2021; Available from: https://ods.od.nih.gov/factsheets/Selenium-HealthProfessional/.
  5. Wallace, T.C. and V.L. Fulgoni, Usual Choline Intakes Are Associated with Egg and Protein Food Consumption in the United States. Nutrients, 2017. 9(8).
  6. Weeks, B.S., M.S. Hanna, and D. Cooperstein, Dietary selenium and selenoprotein function. Medical science monitor : international medical journal of experimental and clinical research, 2012. 18(8): p. RA127-RA132.
  7. Baghdasarian, S., et al., Dietary Cholesterol Intake Is Not Associated with Risk of Type 2 Diabetes in the Framingham Offspring Study. Nutrients, 2018. 10(6).
  8. Lin, H.P., et al., Dietary Cholesterol, Lipid Levels, and Cardiovascular Risk among Adults with Diabetes or Impaired Fasting Glucose in the Framingham Offspring Study. Nutrients, 2018. 10(6).
  9. Pourafshar, S., et al., Egg consumption may improve factors associated with glycemic control and insulin sensitivity in adults with pre- and type II diabetes. Food Funct, 2018. 9(8): p. 4469-4479.
  10. Fuller, N.R., et al., The effect of a high-egg diet on cardiovascular risk factors in people with type 2 diabetes: the Diabetes and Egg (DIABEGG) study-a 3-mo randomized controlled trial. Am J Clin Nutr, 2015. 101(4): p. 705-13.
  11. DiBella, M., et al., Choline Intake as Supplement or as a Component of Eggs Increases Plasma Choline and Reduces Interleukin-6 without Modifying Plasma Cholesterol in Participants with Metabolic Syndrome. Nutrients, 2020. 12(10).

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Make Every Bite Count – Information & Resources for Healthcare Professionals to Share with New Parents

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Make Every Bite Count:

Information & Resources for Healthcare Professionals to Share with New Parents

Katie Hayes, RDN

Eggs Across the Lifespan

Nutritious Dietary Patterns

At the Egg Nutrition Center, we commend Healthcare Professionals (HCPs) and their unwavering commitment to science as they make practical recommendations to their patients and clients. Staying abreast of current evidence is critical as HCPs craft their guidance and education. 

In order to help HCPs offer their patients and clients comprehensive information on eggs as a first food for growth and development, allergy risk reduction, and feeding tips, we created “Make Every Bite Count” booklets (download here) and a poster (download here) that can be printed and shared. Why is this information important to share with parents and caregivers? Keep reading! 

The newly released 2020-2025 Dietary Guidelines for Americans include recommendations for birth to 24 months old, and specifically recommend eggs as an important first food for infants and toddlers, as well as for pregnant women and lactating moms.1 This historic recommendation, coupled with the evolving evidence about infant feeding and allergen guidance from the American Academy of Pediatrics, arms practitioners with a clear message, “Parents can make every bite count by feeding eggs as a fundamental first food.”

In 2019, the American Academy of Pediatrics (AAP) updated their policy on the introduction of potentially allergenic complementary foods. Feeding common food allergens, such as eggs, when a baby is developmentally ready (between 4-6 months) may actually reduce the chances of developing an allergy to that food.2

Additionally, in their 2018 policy statement advocating for improving nutrition in the first 1,000 days, the AAP stated: “Although all nutrients are necessary for brain growth, key nutrients that support neurodevelopment include protein; zinc; iron; choline; folate; iodine; vitamins A, D, B6, and B12; and long-chain polyunsaturated fatty acids. Failure to provide key nutrients during this critical period of brain development may result in lifelong deficits in brain function despite subsequent nutrient repletion.”3

Eggs are affordable, accessible, and versatile. Eggs contain various amounts of all the nutrients listed by the AAP as essential for brain growth, including being an excellent source of choline, which plays a vital role in neurocognition during the first 1,000 days of life. With 90% of brain growth happening before kindergarten, eggs help make every bite count, especially when babies are just being introduced to solid foods. These recommendations confirm what the science has shown: eggs provide critical nutritional support for brain health, and they play a crucial role in infant development and prenatal health. Just one large egg provides the daily choline needs for babies and toddlers, and two large eggs provide more than half of daily choline needs for lactating moms.

Eggs are a nutrient-dense powerhouse. They provide an excellent source of vitamin B12, biotin, iodine, selenium, and choline; a good source of high-quality protein, riboflavin, and pantothenic acid; as well as the carotenoids lutein and zeaxanthin.4

For more information and shareable handouts, videos, and more visit our materials page

  1. U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2020-2025 Dietary Guidelines for Americans. 9th Edition. December 2020. 
  2. Greer, F.R., S.H. Sicherer, and A.W. Burks, The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed Formulas, and Timing of Introduction of Allergenic Complementary Foods. Pediatrics, 2019. 143(4).
  3. Schwarzenberg SJ, Georgieff MK. Advocacy for Improving Nutrition in the First 1000 Days to Support Childhood Development and Adult Health. Pediatrics, 2018. 141(2)
  4. U.S. Department of Agriculture and Agricultural Research Service. FoodData Central. 2019; Available from: https://fdc.nal.usda.gov/index.html. 

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